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Breaking News: CMS Finalizes Interoperability and Prior Authorization Rule to Enhance Healthcare Efficiency

What You Need to Know: CMS-0057-F Fact Sheet

The Centers for Medicare & Medicaid Services (CMS) has issued the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), reinforcing its dedication to streamlining healthcare processes and promoting data sharing. This critical rule mandates that various payers implement advanced data exchange systems, making healthcare information more accessible and prior authorizations faster and more transparent. Here’s a breakdown of the major takeaways:

Key Updates in the Final Rule

1. Streamlined APIs for Data Sharing

Impacted payers—such as Medicare Advantage (MA) organizations, Medicaid programs, and Qualified Health Plan (QHP) issuers—are now required to adopt and maintain Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs). These APIs will:

• Improve electronic healthcare data exchange.
• Reduce administrative burdens associated with prior authorization.

Compliance Timeline:

• API-related requirements begin January 1, 2026.
• Full implementation of enhanced APIs by January 1, 2027.

2. Patient Access API Enhancements

Payers must expand their Patient Access APIs to include detailed prior authorization data (excluding drugs). Patients will gain a clearer view of their prior authorization status and its effect on their care.

Reporting Requirements:
Beginning January 1, 2026, payers must provide annual metrics on API usage to CMS.

3. Provider Access API

To support care coordination, impacted payers must establish Provider Access APIs, enabling healthcare providers to access:

• Claims and encounter data.
• Data classes defined by U.S. Core Data for Interoperability (USCDI).
• Prior authorization details (excluding drugs).

Patients will have the ability to opt out of sharing their data with providers.

4. Payer-to-Payer API for Continuity of Care

A new Payer-to-Payer API will facilitate seamless transfer of healthcare data when patients change insurers. This includes:

• Claims and encounter data (excluding financial details).
• Prior authorization information (for services other than drugs).

5. Prior Authorization API

Impacted payers must develop Prior Authorization APIs to:

• List covered services and documentation requirements.
• Provide real-time status updates, including approvals, denials (with reasons), or requests for additional information.

Fast Decision Timelines:

• Expedited requests: Decisions within 72 hours.
• Standard requests: Decisions within seven days.

Compliance for these APIs begins January 1, 2027.

Transparency and Reporting Requirements

From March 31, 2026, payers must publicly post prior authorization metrics, such as approval and denial rates, on their websites to enhance transparency.

MIPS and Interoperability Programs

CMS introduces an Electronic Prior Authorization Measure for MIPS clinicians and hospitals:

• Implementation Date: CY 2027 performance period.
• Clinicians and hospitals will attest to using certified technology for at least one electronic prior authorization request.

Required Standards and Recommendations

The final rule specifies the use of FHIR® Release 4.0.1 and other interoperable frameworks, along with recommended implementation guides such as the HL7 Da Vinci Project standards, to ensure seamless data exchange.

What Did We Learn?

• Interoperability is the future of healthcare: By mandating advanced APIs, CMS is improving data sharing and reducing barriers for providers and patients alike.
• Prior authorization will become faster and more transparent: New timelines and APIs will streamline the process, enhancing patient care.
• Technology adoption is key: Providers and payers must prepare to integrate these requirements into their workflows by 2027.

FAQs

Who does this rule impact?

The rule affects Medicare Advantage organizations, Medicaid and CHIP programs, QHP issuers, and other federally regulated payers.

What is the timeline for compliance?

Key requirements begin on January 1, 2026, with full implementation by January 1, 2027.

What are the benefits of these APIs?

The APIs improve access to patient data, streamline prior authorization, and facilitate smoother transitions between payers.

Summary

The CMS Interoperability and Prior Authorization Final Rule represents a significant leap toward a more efficient, transparent, and patient-centered healthcare system. It underscores CMS’s commitment to leveraging technology to reduce administrative burdens and improve patient outcomes.

Read official here CMS Interoperability and Prior Authorization Final Rule CMS-0057-F | CMS